Trilliant Health, a healthcare data analytics and advisory shop based in Tennessee, has run some projections on the US healthcare market and telehealth, and they’re not as bright as many of us–and a lot of investors plus Mr. Market–have believed. It opens up on page 4 of the electronic document (also available in PDF) with this ‘downer’–that the largest sector of the largest global economy is overbuilt and unsustainable. Hospitals and health systems have operated for decades that basic economic factors–demand, supply, and yield–don’t apply, and there are more companies competing with them for the consumer healthcare dollar than they realize–with more proliferating every day.
Sledding through their 160-page report, we turn to our sweet spot, telehealth, and Trilliant is not delivering cheerful news (pages 32-43).
- Unsurprisingly, demand for telehealth is tapering off. Based on claims data for face-to-face video visits, excluding Medicare fee-for-service (Original Medicare) and self-pay visits, they peaked above 12 million in April 2020 and, save for a bump up in December 2020-January 2021, steadily declined to about 9 million by March 2021.
- Teladoc, the leading provider, is projecting that 2021 volume will only represent 4 percent of the US population–a lot more than before, but not growing as it did in 2020.
- Telehealth’s growth was astronomical on both coasts–California, Massachusetts, Vermont, Oregon–and Hawaii–but relatively lower in middle and Southern America in places like Wyoming, North Dakota, Mississippi, and Iowa. Telehealth usage is declining sharply in that region as well but across the board in all states including California. In fact, Phoenix and Dallas had higher telehealth utilization pre-pandemic than during it.
- Mental health drove telehealth growth during the pandemic, representing 35 percent of claims, almost four times the next group of categories at 8 percent. The largest group of diagnoses were for anxiety and depression among women 20-49. With the reopening of the US economy and children heading back to school, will this sustain or decline?
- Women 30-39 are the largest users of telehealth–pre, during, and post-pandemic
Telehealth is not only proliferating, it is going up against now-open urgent care, retail clinics from Walgreens, Walmart, and CVS, plus tech-enabled providers that blend virtual care with home care, such as Amazon with a full rollout of Amazon Care and other employers. The cost of care is also a negative driver. FierceHealthcare analyzes other parts of the report impacting practices, health systems, and hospitals.
Some of the universal effects of the COVID-19 pandemic and the prolonged lockdown, lifting in practically all of the US and starting to lift in the UK, is weight gain (‘pandemic pounds’), a changed perception of ‘maintenance’, and in some, a certain reluctance to get back to what was normal life. We are reading that younger workers are reluctant to leave 100 percent remote work and go back to offices at all. Even older workers want to limit in-office time to once or twice a week, having lived free of brutal commutes. Anti-social has become fashionable, based on a simple search of t-shirts for sale (!).
But for the older adult battling to keep engaged and mobile, the toll of prolonged ‘sheltering in place’ has been far greater and less reversible, if at all. A thought piece in Kaiser Health News found that “Large numbers of older adults have become physically and cognitively debilitated and less able to care for themselves during 15 months of sheltering in place.” This includes older adults who did–and did not–have COVID-19.
Doctors are seeing combinations of:
- Weight gain–and weight loss due to lack of interest in eating, not eating or hydrating well
- Depression from lack of contact with family and the outside world
- Cognitive difficulties
- Physical deconditioning, leading to severe lack of mobility and falls. Lack of activity leads to muscle mass loss of up to 20 percent in as little as five days.
- Exacerbation of chronic illnesses such as diabetes, congestive heart failure and chronic obstructive pulmonary disease (COPD)
For those in assisted living, a comeback is made even more difficult with restrictions still in place. Many have deteriorated so much that rehabilitative therapies do little good. The rest of the article describes rehabilitative outreach to those living at home, ranging from in-home physical therapy, to combinations of phone/video/in-home outreach, peer advocates, and encouraging older adults to go see their doctors in person. A follow-up article gives tips for older adults to reemerge in the post-pandemic world, with an emphasis on slowly increasing physical activity, reestablishing routines and social contacts, plus minding one’s diet.
Directional data that confirms the acceptance of telehealth gained five years of progress in one–and that could justify continued massive investment in telehealth. One year after COVID-19 introduced Americans to telehealth as the sole alternative to the in-person medical visit, perceptions have changed positively among users and non-users. Customer engagement/business process services company Sykes Enterprises surveyed 2,000 US adults (18+) in March and found the majority of their respondents not only now believed that they could receive quality care via telehealth, but also that it provided needed care and is preferred for parts of their annual exam, in addition to other specific acceptance points.
Highlights of the survey: (more…)
Do you have a story to share about how COVID-19 has impacted your community–or you or someone you know personally? Healthline.com, a leading US consumer healthcare information website, is seeking stories about how communities that have been impacted by inequities in healthcare have experienced COVID-19. Since many of our Readers are in organizations or businesses that support these communities–such as older adults, the disabled, the rural, in underfunded areas, and/or those who live without access to the internet–you may have a personal story about it. Were you able to overcome it?
Healthline has confirmed to this Editor that stories about communities outside the US are welcome.
Visit or share the following link to submit your story by 14 May. https://transform.healthline.com/submit
There has been a plethora of tracking studies starting last year on how telemedicine stepped in for in-person visits during the early months of the COVID-19 pandemic. Telehealth visits peaked, then tapered off as medical offices reopened. Reviewing our articles:
- Commonwealth/Phreesia: tracking the latter’s practices, they dropped from a high of 13.9 percent on 18 April to 6.3 percent by early October. Where telemedicine use stayed high was behavioral health–psychiatry–which remained at 41 percent.
- Epic Health Research Network’s data, which concentrated on hospitals and clinics, showed a similar drop from the mid-April high of 69 percent but ended August at 21 percent. Regionally, the South had the least takeup of telehealth even in the critical period.
- FAIR Health, using insurer claims data, tracked with Commonwealth/Phreesia from 13 percent in April to 6 percent by August.
The latest study has been just published in Health Affairs (abstract free, paid access full study). Using data from 16.7 million commercially insured and Medicare Advantage enrollees from January to June 2020, the steep rise from a negligible base was the same but the percentages were between the Commonwealth and Epic studies. 30.1 percent of all visits were provided via telemedicine (including telephonic) and the weekly number of visits increased twenty-three-fold compared with the prepandemic period. The database also permitted a deeper analysis of usage.
- Telemedicine use was lower in communities with higher rates of poverty (31.9 percent versus 27.9 percent for the lowest and highest quartiles of poverty rate, respectively). Unfortunately for comparison, not included in the information was the actual rate in wealthy counties.
- Overall visits (in-person and virtual) plummeted by 35 percent, a backlog in deferred care still being made up
- Rural telemedicine use was lower than urban–24 percent versus 31 percent by county
- How specialties incorporated telehealth varied widely. As previously reported, psychiatry had a high uptake of telemedicine and reported the least drop in overall visits. Surprisingly, endocrinology (68 percent) and neurology also had high utilization. Only 9 percent of ophthalmologists reported telehealth use, because the physical exam requires highly specialized equipment.
- Management of chronic conditions was in between those two extremes. Conditions like hypertension and diabetes had a big drop in care volume that was mitigated by a large increase in telemedicine use.
A depression treatment headset and app called Flow is being marketed in the UK and Europe by a Malmö-based company to help treat depression through brain stimulation. The user applies the headset to the forehead area and operates it through the smartphone app. The brain stimulation uses transcranial Direct Current Stimulation (tDCS) to restore brain activity in the frontal lobe to decrease depressive symptoms in as little as three weeks. tDCS has been found in randomized controlled trials to have a similar effect to anti-depressant drugs, but without the side effects. The treatment and company were formed by Daniel Mansson, a clinical psychologist, and neuroscientist Erik Rehn. The system is available for purchase for €45/monthly or outright purchase for €459. (Not available in the US)
‘Lockdown loneliness’ is a renewed concern as the pandemic won’t go away and we are both being advised to restrict our movements, physically distance, normal gathering places are closed or restricted, and in many areas, we are being asked to isolate again from family, friends, and co-workers. A study published in PLOS One from a 1,900+ sample of UK adults 18-87 years of age in March-April indicated the prevalence of self-reported loneliness was very high–27 percent. 49 to 70 percent of respondents reported feeling isolated Reported risk was higher in the younger age group, among those who are separated or divorced, or already meeting clinical criteria for depression or emotion regulation difficulty. Loneliness was measured using the Three-Item Loneliness Scale. With holidays coming up soon, this initial report does not bode well for the rest of the year.
Tim Peck MD, founder of Call9, which provided in-facility emergency care staff with telehealth capability for nursing homes, announced a new venture also targeted to nursing home/skilled nursing home (SNF) and rehabilitative health. Curve Health will provide telemedicine and health information exchange technology to SNFs and physician groups. Physicians calling on SNF patients will be able to access patient information before a telemedicine visit. According to Dr. Peck, Curve Health’s telehealth and HIE software are built on that of Call9’s. POLITICO Morning e-Health.
Call9 closed operations last July after four years and $34 million in investment. It achieved some success in New York state, covering 3,700 beds and a total of 11,000 patients treated. While they experienced measurable success–in a 200-bed SNF, they achieved a 50 percent reduction in ER admissions and a savings of $8M per year–made inroads with major payers like Anthem and Healthfirst plus expanded into community telemedicine, it ran into a funding wall all too common with this sector. While the book of business was decent and they had gone through two well-funded rounds, Call9 could not move easily into a Series C. Value-based care is a great buzzword and beloved by CMS, but it is a long payout curve, too long for many investors. More discussion on this is in our article 26 June 2019.
It is a shame as New York has been the epicenter of COVID-19 nursing home fatalities, due to a foolish (and this Editor is understating) state mandate of returning recovering patients right back to their nursing homes, which could not provide the level of care or isolate them. These patients often worsened, but also infected other patients and staff. Perhaps this could have been mitigated by Call9 or similar–but likely not.
Sadly, there’s a spotlight on nursing homes, rehabs, and LTC because of this pandemic. We look forward to more news from Dr. Peck and Curve Health in this specialized and underserved area of telehealth.
Further to my write-up of the SIHI big data conference in Portsmouth, Wired has just published an excellent summary of Nuria Oliver’s presentation on how analysing anonymised mobile phone information made a significant contribution to understanding the dynamics of the recent H1N1 flu outbreak in Mexico in 2009.
Worth a read.